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CMS Program Audit and Compliance Monitoring Solution For Health Plans CMS Program Audit and Compliance Monitoring Solution For Health Plans

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        Universe Scrubber

        Traditionally, health plans commit resources for months while setting up all the data to comply with regulatory audits. Inovaare optimized the implementation process so that health plans can start using this powerful CMS universe validation and report generation tool within a week.

        Inovaare’s Universe Scrubber scrubs Centers for Medicare and Medicaid (CMS) Program Audit universe reports and flags all crucial errors. This, alone, optimizes operational efficiency.

        However, Universe Scrubber also analyzes universe tables for authorizations, claims, appeals and grievances CMS universes—such as Part C Organization Determinations, Appeals and Grievances (ODAG), Part D Coverage Determinations, Appeals and Grievances (CDAG) and Medicare-Medicaid Plan Service Authorization Requests, Appeals and Grievances (SARAG)—and other regulatory universes in real time. Payers can also monitor the health of their plans, on demand, by running Universe Scrubber monthly, weekly or even daily.

        With all CMS universe tables embedded, Universe Scrubber provides access to real-time data so health plans can validate their CMS Program Audit universe tables in three simple steps:

        1. Upload universe file
        2. Scrub to validate
        3. Review and publish

        Universe Scrubber empowers health plans to:

        • Identify turnaround times and outlier issues, as well as errors in universe formatting, data and business logic
        • Proactively audit and monitor first-tier, downstream and related (FDR) delegated entities
        • Reduce effort in preparing universe submissions
        • Increase productivity by improving collaboration within the organization
        • Benefit from preconfigured business rules based on up-to-date regulatory mandates
        • Customize configuration based on company-specific business rules
        • Make better decisions based on automated analytics that leverages real-time data to generate intuitive dashboards and KPI reports

        Inquire how

        Universe Generator

        Health plans can reduce the risk of penalties and lower CMS Star Ratings by increasing report turnaround times. Universe Generator will do just that by enabling users to create properly formatted universes with the click of a button.

        Universe Generator gathers data for requested date ranges to create clean universes for submission, even from multiple submitters providing the same universe table. It then compiles scrubbed universes into a single table for continuously compliant CMS report submission.

        Universe Generator can be prebuilt with each report in the approved format for layout and data type and, when used regularly, this tool empowers payers to continuously monitor the health of their plans.

        Additional benefits allow compliance teams to:

        • Generate universes with reduced dependency on IT teams
        • Meet their own data requirements or query requests
        • Maintain audit readiness at all times

        Inquire how

        FDR Universe Manager

        Work collaboratively with your delegated entities through our FDR Portal, which accesses and consolidates CMS Program Audit universes submitted by delegates. This efficiency ensures health plans can produce more accurate results with fewer resources to manage, monitor and audit FDRs.

        FDR Universe Manager allows a health plan’s delegated entities to scrub and submit universes for review and potential remediation through a secure portal. This reduces the back-and-forth communication typically required for delegate universe submissions.

        The automated workflow takes care of the manual processes to:

        • Identify outliers
        • Expose potential risks
        • Achieve faster turnaround times
        • Reduce effort and costs
        • Track FDR submissions and issues

        Inquire how

        Provider Dispute Resolution

        Most states require health plans to pay healthcare providers accurately and timely for their services. In parallel, payers must maintain a fast, fair and cost-effective system for processing and resolving provider claims. Health plans must also submit annual reports regarding the number, type and provider claim payment-dispute summaries. They are required to describe the resolutions including terms and timeliness and explain how they are addressing trends or patterns in disputes.

        With Provider Dispute Resolution (PDR), health plans can:

        • Monitor and manage PDR processes efficiently
        • Track provider disputes in real time
        • Ensure consistent compliance

        Inquire how

        QIO Appeals

        The Quality Improvement Organization (QIO) Program, one of the largest federal programs dedicated to improving health quality for Medicare beneficiaries, is an integral part of the U.S. Department of Health and Human (HHS) Services’ National Quality Strategy for providing better care and outcomes at lower costs. CMS relies on QIOs to improve the quality of healthcare for all Medicare beneficiaries.

        Inovaare’s QIO Appeals solution helps:

        • Ensure QIOs are tracked at each step, from intake through closure
        • Guarantee each decision rendered is executed efficiently
        • Support timeliness

        Inquire how

        Issue Management

        Architected by CMS regulatory compliance experts, Inovaare ensures health plans can effectively track and manage issues that have been identified as a risk or potential non-compliance. This includes automating corresponding follow-up actions and activities. Inovaare's Incident Management module empowers regulatory compliance management teams to drive continuous improvement activities across the entire enterprise. Now, payers can analyze trends, draw insights across multiple departments, implement and track corrective actions and then accurately measure real-time results.

        Inovaare ensures health plans can:

        • Facilitate and centralize any incident that could potentially be a risk to the organization
        • Determine if it is a risk or not (pre-screen or triage the risk/incident)
        • Track resolution from start to finish
        • Incident tracking & reporting (FWA, SIU, etc.)

        Inquire how

        Corrective Action Plan (CAP)

        Inovaare’s Corrective Action Plan module automates CAP monitoring, assigns issues for resolution and records results of root-cause analysis. Now, health plans can:

        • Automate or simplify the approval process
        • Implement tasking and reporting
        • Expedite resolution of issues identified within the organization and non-compliance issues regarding customer complaints
        • Monitor CAP results to reduce errors, perform trend analysis and identify the root-causes

        Inquire how

        Regulatory Library

        Inovaare’s cloud-based Regulatory Library module ensures an efficient process is in place to manage memos and ensure health-plan compliance is not consistently at risk. It equips health plans to streamline review processes and coordinate communication across all departments as well as update and monitor required due dates.

        In addition to the ability to auto-load HPMS memos, efficiently monitor State Notices and improve department adherence to memorandums and quickly identify any corrective actions, health plans benefit from:

        • Regulations Upload: Centralized location to upload & review regulations
        • Task Management: Provides ability to create, manage & track tasks by department, state and line of business (LOB)
        • Analytics Dashboard & Reports: Available for regulations and tasks by state, LOB, department, due date, count, risk level, status, owners, etc.
        • Citation & Hyperlinks Creation: Available for uploaded regulations
        • Keyword Search: Search regulations by ID, type, date, etc.
        • Compliance Acknowledgement: Record of effective compliance communication via the ability to attach proof of Compliance & Compliance Manager to approve & acknowledge the compliance
        • Risk Management: Potential risks can be identified, tracked & mitigated by effectively communicating with Operational & Compliance stakeholders
        • Automated Reminders and Notifications: Internal/external stakeholders and PGA (Policy & Government Affair) can receive timely notifications and reminders
        • Communication: Collaborate with regulatory owners, functional owners, compliance owners & other organization stakeholders

        Inquire how

        Contract & Policy Tracking

        Enable proactive management of all contracts including those with vendors, service providers, customers and business partners. Facilitate collaboration using fully customizable workflow processes for review and approval.

        Features:

        • Track communications between you and your regulator
        • Simplify the approval process
        • Monitor key deliverable dates

        Benefits:

        • Manage contract life cycle
        • Track and monitor compliance as well as regulatory quality management
        • Access to a central compliance system that connects different departments and systems

        Inquire how

        Policies & Procedures

        Policies and Procedures is a comprehensive cloud-based platform built for the healthcare industry that allows organizations to publish, assess and manage their policies and procedures. Health plans can create and/or review drafted policies, signoff and automate the full life-cycle management process of policies and procedures, including customizable workflows for review and approval.

        Inovaare's cloud-based Contract and Policy Tracking module allows regulatory compliance management teams to:

        • Collaborate across the entire health plan as well as store and manage all regulatory contracts and policies
        • Automate the contract and policy life cycle to increase productivity
        • Find documents and manage expiration dates—including Optical Character Recognition (OCR)

        Inquire how

        Risk Management

        Inovaare’s Risk Management solution surveys and gathers evidence to determine risk. The module provides a single interface that users can access to create and edit attestations as well as change scoring parameters. Health plans can: complement existing risk-management policies and procedures with templates, metrics and workflows; minimize and manage corporate risks to lower the risk levels and reduce the organization’s direct costs; and maintain end-to-end audit trails.

        Inovaare’s cloud-based Risk Management module empowers health plans to:

        • Exert stronger control over a wide array of internal and external risks including market, strategic, financial, operational, IT, legal, brand issues
        • Minimize and manage reputation-related issues
        • Integrate and monitor corrective action plans

        Inquire how

        Internal Audit

        Demand for continuous risk management and control systems is on the rise, so organizations are adopting automation to support their audit teams. Inovaare’s Internal Audit module helps health plans manage end-to-end audit processes efficiently by delivering a systematic, risk-based audit system that streamlines workflows and provides real-time reporting. This allows health plans to attain a holistic view of the organization’s governance, risk and compliance status.

        This cloud-based audit solution empowers health plans to:

        • Drive an agile internal audit program aligned with organizational goals
        • Prepare for multi-dimensional risks, while preserving the trust of every stakeholder
        • Reduce the time spent on sifting through mountains of data to mine insights
        • Increase productivity and accelerate business performance
        • Manage a wide range of audit activities, data and processes in a unified manner

        Key Features

        • Facilitates a structured, risk-based approach to internal and external audits across the enterprise.
        • Integrates audit life cycles, including audit planning and scheduling, checklist preparation, field data entry, audit report generation, corrective actions and risk mitigation
        • Provides a comprehensive picture of the audit activities status
        • Stores and organizes audit questionnaires and worksheets regarding findings, non-compliance, observations, documentation and all relevant corrective actions

        Benefits

        • Improve business performance by aligning audits with strategic objectives and risks
        • Optimize audit productivity by prioritizing resource allocation based on the areas of highest risk impact
        • Increase collaboration by standardizing the audit execution methodology across teams
        • Simplify control-testing processes using a streamlined approach, which frees up time for value-added activities

        Inquire how

        Internal Monitoring

        Sustaining compliance is a challenge, since CMS and state regulatory requirements change frequently. However, by implementing internal checks and reviews, health plans can gain better visibility of their quality control and compliance processes.

        Continuous monitoring of your compliance program not only helps improve operational health, but it demonstrates to the CMS that your health plan takes compliance seriously. Inovaare’s Internal Monitoring solution assists health plan to:

        • Streamline review processes to ensure necessary policies and procedures help minimize compliance risks
        • Support collaboration across teams
        • Optimize workflows to improve turnaround times
        • Lower operating costs while improving remediation processes

        Inquire how

        External Audit

        External auditors are essential to ensure health plans meet their governance, risk management and compliance (GRC) requirements. Inovaare’s External Audit solution enhances the exchange process through its compliance-driven platform.

        Embedded with all applicable federal and state regulations — including Medicare Part C, Medicare Part D and Medicaid — this cloud-based module helps heath plans to:

        • Support transparency and increase risk awareness to facilitate better decision making
        • Align audits to strategic objectives and risks
        • Optimize audit productivity by prioritizing resource allocation based on the areas of highest risk impact
        • Standardize the audit execution methodology across teams

        Inquire how

        Delegation Oversight

        Inovaare’s Delegation Oversight module enables health plans to manage first-tier, downstream and related (FDR) delegated entity compliance. Now, Delegation Oversight departments can perform systematic reviews of FDR operations—to ensure they are in line with business requirements—while empowering plan sponsors and MCOs to manage and track all audits and monitoring of delegated entities. The module also provides a secure portal for communication where delegated entities can scrub their universe files before submitting them to the health plan.

        Features

        • FDR Audit
        • FDR Monitoring
        • FDR Scheduling
        • FDR CAP
        • FDR Tracking & Scoring

        Inquire how

        Member Services

        Experience the difference. Inovaare’s CRMؙ—Member Services is the only solution that shares the same platform as Appeals & Grievances and CRM—Provider Services. This singular platform delivers better member experiences powered by end-to-end workflow automation. Inovaare’s CRM—Member Services was architected by leaders who oversaw Member Services departments and, as a result, we understand your requirements for Medicare, Medicaid and Commercial plans. Our industry-leading solution helps health plan to:

        • Eliminate misclassified cases
        • Increase staff productivity with 2-click case closures
        • Empower the entire Member Services department with embedded Knowledge Management

        Inquire how

        Provider Services

        Experience the difference. Inovaare’s CRM—Provider Services is the only solution that shares the same platform as CRM—Appeals & Grievances and CRM—Member Services. This singular platform delivers better provider experiences powered by end-to-end workflow automation. Inovaare’s CRM—Provider Services was architected by leaders who oversaw Provider Services department and, as a result, we understand your requirements for Medicare, Medicaid and Commercial plans. Our industry-leading solution helps health plans to:

        • Obtain a 360⁰ view of all provider issues
        • Increase staff productivity with 2-click case closures
        • Empower the entire Member Services department with embedded Knowledge Management

        Inquire how

        CMS Program Audit & Compliance Monitoring

        Manage CMS Program Audit and Compliance Monitoring with the touch of a button

        Demystify Program Audit Management

        Build orderly universes in the beginning to achieve the biggest bang at the lowest cost​

        • Internal Audit

          Centralize data to facilitate stronger collaboration and drive regulatory compliance

        • Internal Monitoring

          Review real-time status of all findings, recommendations and corrective action plans

        • External Audit

          Facilitate efficient collaboration and secure data exchange with outside agencies

        • Delegation Oversight

          Collaborate efficiently with first-tier, downstream and related (FDR) delegated entities

        Centralize Secure Audit Data

        Improve Collaboration Across Teams

        Sustain Continuous Audit Readiness

        Integrate External Communications

        Manage FDR Compliance

        Since the CMS program audit utilizes various universes—such as Part C Organization Determinations, Appeals and Grievances (ODAG), Part D Coverage Determinations, Appeals and Grievances (CDAG) and Medicare-Medicaid Plan Service Authorization Requests, Appeals and Grievances (SARAG)—to evaluate health plan performance, it’s essential for audit and monitoring teams to leverage real-time data. Yet, despite current innovations to address CMS Program Audits, it has been a perpetual challenge for health plans to create and submit accurate, timely universes to avoid invalid data submissions and poor audit scores.

        Many healthcare organizations still rely on time-consuming manual program-audit processes, which are often riddled with errors, inconsistencies or both. However, having over 125 years of combined audit and monitoring expertise, Inovaare knows that by automating the process, health plans can be better prepared to generate and validate accurate, clean universes that are ready for submission. As a result, they will improve operational efficiency and achieve a healthier bottom line.

        Minimize CMS program audit errors with workflow automation

        Internal Audit

        Efficiently oversee compliance readiness through regular mock audits based on current CMS Program Audit protocols. Merge different workflows and maintain a system-wide overview of all compliance activities. This cloud-based solution empowers healthcare compliance teams to:

        Monitor Program Audit universes proactively

        Internal Monitoring

        Create a culture of compliance by monitoring your health plan’s processes to improve operational health and create a better member experience. Our Internal Monitoring module, with all federal and state rules and regulations embedded, helps health plans to:

        Minimize program audit errors with workflow automation

        External Audit

        Improve turnaround time and facilitate more responsive collaboration with external auditors while promoting compliance every step of the way. This cloud-based solution supports health plans to:

        FDR MANAGEMENT FOR END-TO-END PROGRAM AUDIT COMPLIANCE

        Delegation Oversight

        Systematically conduct audits and perform file reviews of first-tier, downstream and related (FDR) delegated entities to create a culture of compliance within the areas of Credentialing, Utilization Management, Quality Improvement and other delegated functions. This essential software module can:

        Key CMS Program Audit & Monitoring Benefits

        • Intuitive real-time dashboards and reports for health-plan management, audit committees and stakeholders
        • Standardized workflow-driven audit processes that minimize errors
        • Optimized audit-process visibility, simplifying risk management and compliance
        • Expedited feedback processes to mitigate operational and enterprise risks
        • Increased productivity, by facilitating collaboration within your organization
        • Tracked findings, recommendations and action plans
        video-img

        Take a lighthearted tour within a fictitious health plan as they fret over a CMS Program Audit . . . until Inovaare’s industry-leading solution saves the day.

        UNIVERSE MANAGEMENT OVERVIEW: VIDEO

        UNIVERSE MANAGEMENT SYSTEM

        Ensure your health plan submits accurate, properly formatted CMS regulatory reports with the touch of a button.

        CMS AUDIT BLOG

        Are you ready for 2022? Forewarned is Forearmed: Prepare for 2021 CMS Audit Protocol Changes will help.

        AUDIT READINESS WEBINAR

        Explore how to proactively manage universes in this webinar: Compliance Favors Only the Prepared Plan.

        UNIVERSE SCRUBBER OVERVIEW: VIDEO

        Discover how Universe Scrubber can revolutionize the audit preparation processes.

        ag_enterprise-1

        Learn how a Fortune 500 health plan serving Medicare and Medicare-Medicaid (MMP) members achieved an 80% reduction in CMS Program Audit data-submission efforts.

        CASE STUDY